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SJ (, Environmental Health Department <br /> '4COU��rrNTY• <br /> UST SYSTEMA RETROFIT OR REPAIR <br /> (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) <br /> 1 , Site map enclosed? YES y)/ NO [ ] <br /> 2 , Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training <br /> certificates for each person Installing or testing any component that is repaired or replaced. Ensure a copy of <br /> the "Slee Health and Safety Plan' Is available on the jobsite as required by Title 8 , <br /> 3, Detailed description of work to be completed. List components to be repaired or. replaced and attach a <br /> diagram drawn to scale showing location of repairs and/or replacements , If repairing a component, describe <br /> how this will be done . (if AddjW piping , UDC's , or other UST equipment, or performing tank top upgrade, <br /> use the UST Installation Application pages 4-8 as necessary for a timely plan review): <br /> 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> J Oy <br /> ------------- <br /> 5 . Decontamination Procedures : <br /> a , Will piping be decontaminated prior to removal? YES [g'''am NO [ <br /> b . Identify contractor performing decontamination: <br /> Name Phone S <br /> Address ! r ff t €;, , "[ Clty zip ' .I a3 <br /> 3of6 <br />